Kindergarten Screening and Visit

Please complete both pages, sign and return this form with your application no later than
Tuesday, December 15, 2009.
Child’s Name ______________________________________ Birthdate______________
Parent/Guardian Name(s)___________________________________________________

If you are applying to Katherine Delmar Burke School and/or The Hamlin School, applicants must
complete both a kindergarten screening off site, and a kindergarten visit to each school they are
applying.
Please go to www.kdbs.org/screening/ after November 1st to schedule your child’s kindergarten
screening. These one-on-one assessments will be administered by independent screeners at the
Congregation Emanu-El of San Francisco (2 Lake Street) in January 2010. The screening times
are: 9:00 a.m., 10:00 a.m. and11:00 a.m. If you are also applying to Marin Country Day School,
Mount Tamalpais School and/or St. Mark’s School, you have the option of completing the
kindergarten screening at one of these schools in lieu of screening at Congregation Emanu-El.
Screening results, with your permission, will be shared with the schools you indicate on this form.

In addition to the screenings, all applicants will visit each school to which they are
applying. Please select the date and time you would like to schedule your child’s visit to Burke’s
on the following page.

I. Kindergarten Screening Location:

Please indicate below where your child will have her screening completed.

Testing Site Please check one

Congregation Emanu-El, San Francisco

(for Burke’s and Hamlin)

Marin Country Day School

Mount Tamalpais School

St. Mark's School

(CONTINUED)
II. Schools to Receive Screening Results:
Your signature on this form indicates your permission to share the results of the screening with
the schools named below.

Schools Please check all that apply

Katherine Delmar Burke School

The Hamlin School

Marin Country Day School

Mount Tamalpais School

St. Mark's School

III. Kindergarten Visit at Katherine Delmar Burke School

Please rate in order of preference from 1st to 3rd the date and time you would like your child to visit
Burke’s. We will contact you to confirm the visit date and time.

Saturday 9:00 - 10:00 a.m. Saturday 11:30 a.m -12:30 p.m.

______ January 9 ______ January 9

______ January 16 ______ January 16

______ January 23 ______ January 23

Please list if your child has any food allergies: ___________________________________

____________________________ __________________________________ ___________

Parent/Guardian Signature Parent/Guardian Name (Please Print) Date